"You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review

Importance

The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.

Observations

Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.

Conclusions and Relevance

The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model

Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.

Radical hospitality: Innovative programming to build community and meet the needs of people who use drugs at a government-sanctioned overdose prevention site in San Francisco, California

BACKGROUND

The Tenderloin Center (TLC), a multi-service center where people could receive or be connected to basic needs, behavioral health care, housing, and medical services, was open in San Francisco for 46 weeks in 2022. Within a week of operation, services expanded to include an overdose prevention site (OPS), also known as safe consumption site. OPSs have operated internationally for over three decades, but government-sanctioned OPSs have only recently been implemented in the United States. We used ethnographic methods to understand the ways in which a sanctioned OPS, situated in a multi-service center, impacts the lives of people who use drugs (PWUD).

METHODS

We conducted participant observation and in-depth interviews June-December 2022. Extensive field notes and 39 in-depth interviews with 24 TLC guests and 15 TLC staff were analyzed using an inductive analysis approach. Interviewees were asked detailed questions about their experiences using and working at the TLC.

RESULTS

TLC guests and staff described an atmosphere where radical hospitality-welcoming guests with extraordinary warmth, generosity, and unconditional acceptance-was central to the culture. We found that the co-location of an OPS within a multi-service agency (1) allowed for the culture of radical hospitality to flourish, (2) yielded a convenient one-stop shop model, (3) created a space for community building, and (4) offered safety and respite to guests.

CONCLUSIONS

The co-location of an OPS within a multi-service drop-in center is an important example of how such an organization can build positive sociality among PWUD while protecting autonomy and reducing overdose mortality. Overdose response and reversal is an act of relational accountability in which friends, peers, and even strangers intervene to protect and revive one another. This powerful intervention was operationalized as an anti-oppressive, horizontal activity through radical hospitality with a built environment that allowed PWUD to be both social and safe.

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital

BACKGROUND

People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.

METHODS

We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.

RESULTS

Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.

CONCLUSIONS

Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

The multiple makings of a supervised consumption service in a hospital setting

BACKGROUND

Whereas supervised consumption services (SCSs) are common in many community settings, they are seldomly found in acute care hospitals. As hospitals present unique circumstances that can shape the impacts of an SCS, careful consideration of local implementation contexts and practices is required. We explored the pre-implementation stage of an SCS, to examine how an SCS is made and made differently in relation to the material-discursive context of the hospital.

METHODS

We conducted 11 focus groups with 83 staff and clinicians at an inner-city hospital in Toronto, Canada. Data analysis followed principles of grounded theory and was informed by an 'evidence making interventions' framework.

RESULTS

While most participants indicated they would support the establishment of an SCS at the hospital, multiple enactments of an SCS emerged. An SCS was enacted: as a means to reduce drug-related risks for all people who use drugs, as an opportunity to intervene on patients' drug use, as a means to centralize drug use, and as a transformative intervention for the hospital. In our findings, harm reduction, abstinence, security, and risk mitigation goals existed closely together, yielding overlaying realities.

CONCLUSION

Our findings revealed various enactments of an SCS, some of which are likely to negatively affect people who use drugs and service access. As more hospitals consider the implementation of an SCS, understanding how an SCS is made in practice will be key to building a service that focuses on the needs of people who use drugs.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

BACKGROUND

People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.

METHODS

A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.

FINDINGS

The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.

CONCLUSION

This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis

BACKGROUND AND AIMS

Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections.

METHODS

We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes.

RESULTS

We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission).

CONCLUSIONS

Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.

Response to substance use during hospitalization: A survey study of current and ideal policies and practices

People may use nonprescribed substances during an acute hospitalization. Hospital policies and responses can be stigmatizing, involve law enforcement, and lead to worse patient outcomes, including patient-directed discharge. In the United States, there is currently little data on hospital policies that address the use of substances during hospitalization. In this cross-sectional study, we surveyed clinicians at US hospitals with Accreditation Council of Graduate Medical Education (ACGME)-accredited addiction medicine fellowships about their current practices and policies and what they would include in an ideal policy. We had 77 responses from 55 out of 86 ACGME-addiction medicine fellowships (63.9%). Respondents identified policies at 21.8% of the institutions surveyed. Current responses to inpatient substance use vary, though most do not match what clinicians identify as an ideal response. Our results suggest that the use of nonprescribed substances during a hospitalization may be common, but a majority of hospitals likely do not have patient-centered policies to address this.

"No Good Choice": What are the Issues of Having no Harm Reduction Strategies in Hospitals?

Background

Despite an increase in methamphetamine use and subsequent hospitalizations, the majority of Canadian hospitals currently lack harm reduction strategies for substance use. This can mean that people with lived experience of methamphetamine use are faced with a number of difficult decisions to make when admitted to hospital. Caring for people with lived experience of methamphetamine use can also be problematic with zero tolerance policies requiring abstinence to be maintained. This analysis set out to understand potential health care issues due to a lack of harm reduction strategies from the prospective of people with lived experience of methamphetamine use as well as health care/service professionals.

Methods

Based on a larger study, this secondary analysis explored issues discussed by people with lived experience of methamphetamine use and health care/service professionals regarding the challenges of providing harm reduction approaches in the hospital setting. A total of 108 individuals with lived experience of methamphetamine use completed a qualitative component of a mixed-method interview. In addition, 31 health care/service professionals participated in virtual focus groups and one-to-one interviews. Responses were analyzed using an ethnographic thematic approach.

Results

People with lived experience of methamphetamine use reported 3 choices upon admission: leave or avoid the hospital, stay but experience unsupported withdrawal, or stay but hide their substance usage from health care professionals. Health care/service professionals described 2 options: uphold zero tolerance that can lead to stigma and a lack of knowledge regarding addiction, or accept harm reduction but be unable to implement such strategies. This could lead to health being compromised due to policy and practice that requires abstinence. Neither group of participants described a good choice for them.

Conclusion

Current policy and education related to substance use needs to be revised.

Barriers and facilitators of naloxone and safe injection facility interventions to reduce opioid drug-related deaths: A qualitative analysis

BACKGROUND

Opioid drug-related deaths continue to be a significant public health concern in the Republic of Ireland (ROI) and Northern Ireland (NI). While both regions have implemented naloxone to reduce drug related deaths, there remains a gap in the implementation of a supervised injection facility (SIF). This study aimed to identify barriers and facilitators to implementing naloxone and a SIF to reduce opioid drug-related deaths in ROI and NI.

METHODS

Semi-structured interviews (n=23) were conducted in ROI and NI with experts by experience (n=8), staff from low threshold services (n=9), and individuals involved in policy making (n= 6). Data were analyzed using coding reliability Thematic Analysis and were informed by the Risk Environmental Framework.

RESULTS

The findings illustrated that stigma within the media, health centers, and the community was a significant barrier to naloxone distribution and SIF implementation. Policing and community intimidation were reported to hinder naloxone carriage in both the ROI and NI, while threats of paramilitary violence towards people who use drugs were unique to NI. Municipal government delays and policy maker apathy were reported to hinder SIF implementation in the ROI. Participants suggested peer-to-peer naloxone delivery and amending legislation to facilitate non-prescription naloxone would increase naloxone uptake. Participants recommended using webinars, Town Halls, and a Citizens' Assembly as tools to advocate for SIF implementation.

CONCLUSION

Local and regional stigma reduction campaigns are needed in conjunction with policy changes to advance naloxone and a SIF. Tailoring stigma campaigns to incorporate the lived experience of people who use drugs, their family members, and the general community can aid in educating the public and change negative perceptions. This study highlights the need for ongoing efforts to reduce stigma and increase accessibility to evidence-based interventions to address opioid drug-related deaths in the ROI, NI, and internationally.

"That Line Just Kept Moving": Motivations and Experiences of People Who Use Methamphetamine

INTRODUCTION

Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient's perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches.

METHODS

This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semi-structured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation.

RESULTS

Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment.

CONCLUSION

Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.

A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services

A substantial body of evidence demonstrates that supervised consumption services (SCS) mitigate a variety of drug-related harms, including decreasing overdose deaths, infectious disease transmission, and connecting people who use drugs (PWUD) to various health and social services. Research on SCS has predominantly been quantitative, though qualitative research on these services has increased substantially over the last decade. Qualitative methods provide a framework for developing a richer and more nuanced understanding of meanings and contexts associated with drug use, health service implementation, and experience. We present findings from a scoping review of qualitative studies on experiences of PWUD with SCS published between 1997 and 2022. In total, forty-two papers were included in this analysis. Four primary themes emerged from our analysis: 1) Influence of SCS on health and wellbeing among PWUD, 2) the physical environment of SCS can be both a facilitator and barrier to use, 3) social resources can shape and reshape the context within which PWUD benefit from SCS, and 4) various intersecting forces at play both support and harm PWUD in relation to their experiences with SCS. We discuss the primary facilitators and barriers of SCS use and conclude with suggestions to inform future qualitative research, SCS implementation, and PWUD-centered approaches to drug policy.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices

Background

Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms.

Methods

Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually.

Results

A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms.

Conclusions

VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

Implementation of a nurse-led overdose prevention site in a hospital setting: lessons learned from St. Paul's Hospital, Vancouver, Canada

Objectives

In May 2018, St. Paul’s Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned.

Methods

Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff.

Results

The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response.

Conclusions

Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

"With a PICC line, you never miss": The role of peripherally inserted central catheters in hospital care for people living with HIV/HCV who use drugs

BACKGROUND

People who use drugs (PWUD), and especially those who inject drugs, are at increased risk of acquiring bloodborne infections (e.g., HIV and HCV), experiencing drug-related harms (e.g., abscesses and overdose), and being hospitalized and requiring inpatient parenteral antibiotic therapy delivered through a peripherally inserted central catheter (PICC). The use of PICC lines with PWUD is understood to be a source of tension in hospital settings but has not been well researched. Drawing on theoretical and analytic insights from "new materialism," we consider the assemblage of sociomaterial elements that inform the use of PICCs.

METHODS

This paper draws on n = 50 interviews conducted across two related qualitative research projects within a program of research about the impact of substance use on hospital admissions from the perspective of healthcare providers (HCPs) and people living with HIV/HCV who use drugs. This paper focuses on data about PICC lines collected in both studies.

RESULTS

The decision to provide, maintain, or remove a PICC is based on a complex assemblage of factors (e.g., infections, bodies, drugs, memories, relations, spaces, temporalities, and contingencies) beyond whether parenteral intravenous antibiotic therapy is clinically indicated. HCPs expressed concerns about the risk posed by past, current, and future drug use, and contact with non-clinical spaces (e.g., patient's homes and the surrounding community), with some opting for second-line treatments and removing PICCs. The majority of PWUD described being subjected to threats of discharge and increased monitoring despite being too ill to use their PICC lines during past hospital admissions. A subset of PWUD reported using their PICC lines to inject drugs as a harm reduction strategy, and a subset of HCPs reported providing harm reduction-centred care.

CONCLUSION

Our analysis has implications for theorizing the role of PICC lines in the care of PWUD and identifies practical guidance for engaging them in productive and non-judgemental discussions about the risks of injecting into a PICC line, how to do it safely, and about medically supported alternatives.

Hospital policy as a harm reduction intervention for people who use drugs

Hospitals are a critical touchpoint for people who use drugs (PWUD). However, hospital policies, both formal and informal, can have a detrimental impact on PWUD in acute care settings. Introducing new policies, or revising existing policies that inadvertently harm or stigmatize PWUD while hospitalized, could be an effective harm reduction intervention for this high-risk population. This paper explores seven areas where institutional policy change could improve the hospital experience of PWUD: (1) use of nonprescribed substances in hospital, (2) supporting inpatient addiction consultation services (3) in-hospital supervised consumption spaces (4) supply and distribution of safe drug use equipment and naloxone, (5) role of security services and personal searches, (6) use of hospital restrictions, and (7) involvement of PWUD in policy development.